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John Bonica Did Not Recognize John Lundy as an Inspiration of His Pain Clinic Model
Letters to the Editor
Ultrasound Guidance for Brachial Plexus Localization With Volkmann’s Contracture of Forearm, and Decompressed Compartment Syndrome To the Editor: After the recently published report by Assmann and colleagues,1 we would like to report another scenario, acute ischemia of the arm complicated by ischemic contracture, for which the safe provision of regional anesthesia would have been difficult without the use of ultrasound. A 61-year-old man was transferred to our hospital with a 24-hour history of severe pain in his left arm secondary to spontaneous thrombosis of the axillary artery. He was immediately scheduled for emergency embolectomy and forearm fasciotomies, the latter in anticipation of reperfusion-induced compartment syndrome. He had significant comorbidity including chronic respiratory failure, for which he was awaiting home oxygen. Prior to induction of anesthesia, the patient described severe pain in his left forearm with no voluntary motor function below the shoulder and early signs of a contracture. A rapid-sequence induction was performed, and anesthesia maintained with desflurane and a remifentanil infusion. No other opioids were used during the procedure. In view of his severe preoperative pain, respiratory failure and likelihood of repeat procedures, it was decided that postoperative analgesia would be best provided by a continuous brachial plexus blockade. Proximal approaches to the brachial plexus were contraindicated due to the underlying lung pathology and also due to full anticoagulation with unfractionated heparin. Therefore an axillary brachial plexus blockade was performed using ultrasound guidance to prevent damage to the newly palpable artery. The neurovascular bundle was clearly seen using a 5 to 10 MHz ultrasound. The nerve stimulator was set to deliver 1.6 mA (100 ms, 2 Hz) and using the long axis view, the tip of a 50 mm insulated needle was seen to approach the median nerve. However no twitches could be elicited. The stimulating current was increased and faint finger flexion observed at 1.9 mA. The motor response did not increase above 1.9 mA, and disappeared below 1.9 mA. Twenty mL of 0.75% ropivacaine was injected, with immediate loss of twitches, and was seen to surround the neurovascular bundle. A perineural catheter was then inserted through the needle. On emergence from anaesthesia the patient was comfortable and an infusion of ropivacaine 0.2% commenced. The patient remained pain-free on the ward and the indwelling perineural catheter was later used to provide anaesthesia for surgical re-exploration and a dressings change at 48 hours. The catheter was inadvertently removed on the ward after three days. After 4 hours the patient began to complain of severe pain in his forearm although his hand remained
464
numb, and the arm immobile. The catheter was re-sited, again using ultrasound, with similar success. This case again illustrates how ultrasound was vital in establishing regional anesthesia due to lack of traditional endpoints, and the importance of avoiding damage to local structures. Furthermore, it describes the use of regional analgesia after decompression of the forearm compartments. There are multiple reports of regional anaesthesia masking compartment syndrome,2,3 but we found no reports of its use after fasciotomy to relieve compartment syndrome. Matthew Ward, M.B. Ch.B., F.R.C.A. Kirk Joseph Christopher Langley, M.R.C.P., F.R.C.A. Department of Anaesthesia and Pain Medicine Royal Perth Hospital Perth, Australia References 1. Assmann N, McCartney CJ, Tumber PS, Chan VW. Ultrasound guidance for brachial plexus localization and catheter insertion after complete forearm amputation. Reg Anesth Pain Med 2007;32:93. 2. Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg 1996;78:499-500. 3. Davis ET, Harris Q, Keene D, Porter K, Manji M. The use of regional anaesthesia in patients at risk of acute compartment syndrome. Injury 2006;37:128-133.
Accepted for publication June 13, 2007. doi:10.1016/j.rapm.2007.06.006
John Bonica Did Not Recognize John Lundy as an Inspiration of His Pain Clinic Model To the Editor: I read with interest the article by Sen et al.1 I am glad that Bonica’s contribution to the fields of pain and anesthesiology are being discussed. However, some of the information in the article is incorrect2 and possibly the conclusion is also erroneous. In 1987, in honor of Bonica’s seventieth birthday, a Symposium was organized in Venice and he was asked to deliver a lecture, “Wrestling with Pain,” an autobiographical summary of his professional and personal life which was videotaped.3 In the section covering the time from graduation from Marquette Medical School in 1941 until the establishment of the concept of the interdisciplinary pain clinic at Madigan Army Hospital, the projected slides show the following selected points: 1942 - 4/44 Anesthesiology Residency – St. Vincent Hospital NYC . . .
Regional Anesthesia and Pain Medicine, Vol 32, No 5 (September–October), 2007: pp 464 –466
Letters to the Editor 6/44 Chief of Anesthesia, Madigan General Hospital (Army) . . . 8/44 S. G. ⬎ Director School of Anesthesia . . . ⫹ Management of Pain . . .
are incorrect and the hypothesis that Bonica’s model of pain therapy was influenced by John Lundy is very likely erroneous. Costantino Benedetti, M.D. Department of Anesthesiology The Ohio State University Columbus, OH
In the video, Bonica states: “. . . following this [graduation from medical school, author note], I went to St. Vincent Hospital in New York which at the time it was considered one of the elite hospitals of New York City . . . In 1942, the war had just started in the United States; there was an abbreviated internship and an abbreviated residency in anesthesiology. Because most faculty anesthesia staff had gone to war, I had one day of instruction on giving anesthesia and for the rest 18 months I was the chief resident of anesthesia . . . Now this hospital . . . was staffed by the great leaders of American anesthesia: Paul Wood, Rovestine . . . and many others. Surgical anesthesia was absolutely first class . . . . Soon after my training, I was inducted in the United States Army, and to my great, great satisfaction and pleasure I was assigned as chief of anesthesia of the biggest military hospital in the world . . . Soon thereafter the Surgeon General of the Army sent me a telegram saying ‘In addition to your other duties . . . you will be responsible for the management of patients with pain.’ This was the time that Le Riche, the great French surgeon, had popularized regional techniques for managing patients with pain and, of course, Livingston had just finished his book on the subject . . . . I had had no training in pain therapy; I knew nothing about pain except how to prevent it with general anesthesia. So I read all the books quickly . . . I taught regional anesthesia to myself by running to the pathology room and obviously I was frustrated because I could not handle the problem. Then I contacted colleagues in neurosurgery, neurology in other places for help. And found that the traditional method of communication, that is for the patient to be seen by each of the consultants and then to try to get this information was very difficult, time consuming, inefficient. And so I got the bright idea, I thought, of getting them together at lunch to discuss these pain problems. And this was really the beginning of the multidisciplinary program approach to pain diagnosis and therapy . . .⬙ From this presentation it is clear that Bonica started his work at Madigan in June 1944 and not in 1942. His main innovation in the field of pain was not that of involving different specialists in the diagnosis and treatment of pain (indeed it already existed), instead it was to have these individuals meet twice weekly to discuss among each other the issues of each individual pain patient as opposed to relying on the written consultants’ notes. He did not recognize John Lundy as one of his inspirations for pain treatment; instead he spoke of LeRiche and William Livingston. There is no question that Bonica knew Lundy quite well, as he spoke to me about him on several occasions. In addition, Bonica’s medical library has several books that were part of Dr. Lundy’s library. However this relationship developed later in Bonica’s life as confirmed by his daughter Angela (telephone conversation with Mrs. Angela Bonica De Simone, June 19, 2007). In conclusion, some of the dates reported in the article
465
References 1. Sen S, Martin DP, Bacon DR. Exploring origins: Was John Bonica’s model of modern-day pain management influenced by John Lundy’s earlier work? Reg Anesth Pain Med 2007;32:258-262. 2. Benedetti C, Chapman R. John J. Bonica: A life dedicated to the alleviation of human suffering. In: Benedetti C, Chapman CR, Giron G, eds. Advances in Pain Research and Therapy. Vol. 14: Opioid Analgesia. New York: Raven Press; 1990:xv-xxii. 3. Bonica J. Wrestling with Pain [videotape]. Venice: Benedetti C. Videotape library; 1987.
Accepted for publication June 27, 2007. doi:10.1016/j.rapm.2007.06.387
Reply to Dr. Benedetti To the Editor: We thank Professor Costantino Benedetti for his very thoughtful, insightful comment on our article. We agree that Bonica’s work began at Madigan in 1944. Somehow in writing our article, we made an error. We believe that we had somehow substituted the end of Dr. Bonica’s medical school training in 1942, with his subsequent residency training in 1944. We apologize for this regrettable error, although it does not alter our thesis. Historical methods are often somewhat different than basic science or clinic research methodology. There is ample evidence of John Lundy’s influence in John Bonica’s career even if they did not know each other at the time. Bonica’s residency was at Saint Vincent’s Hospital in New York City where he was trained by Paul Wood, Emery Rovenstine, and other major figures of the New York City anesthesia scene. All were close personal acquaintances of John Lundy through the Anaesthetists’ Travel Club and the American Society of Anesthesiologists. During Bonica’s residency, Lundy did travel to New York, and therefore they may well have met. Even if they did not make a personal connection, Wood and others would have spoken about Bonica to Lundy. Second, Lundy was heavily involved in the placement of anesthesiologists within military hospitals and the Lundy correspondence housed in the Mayo Foundation Archives is replete with examples of Lundy writing to command staff to have physicians placed appropriately within the specialty.1 Bonica’s commanding surgeon at Madigan, Joel Deutermann, was familiar with Lundy. The practice pattern is similar. The textbook Bonica most likely used was Lundy’s2 because it was the official text for the military short course and the most current comprehensive reference available for residency training. Lundy’s textbook has a large section on regional anesthesia.
Ultrasound Guidance for Brachial Plexus Localization With Volkmann’s Contracture of Forearm, and Decompressed Compartment Syndrome To the Editor: After the recently published report by Assmann and colleagues,1 we would like to report another scenario, acute ischemia of the arm complicated by ischemic contracture, for which the safe provision of regional anesthesia would have been difficult without the use of ultrasound. A 61-year-old man was transferred to our hospital with a 24-hour history of severe pain in his left arm secondary to spontaneous thrombosis of the axillary artery. He was immediately scheduled for emergency embolectomy and forearm fasciotomies, the latter in anticipation of reperfusion-induced compartment syndrome. He had significant comorbidity including chronic respiratory failure, for which he was awaiting home oxygen. Prior to induction of anesthesia, the patient described severe pain in his left forearm with no voluntary motor function below the shoulder and early signs of a contracture. A rapid-sequence induction was performed, and anesthesia maintained with desflurane and a remifentanil infusion. No other opioids were used during the procedure. In view of his severe preoperative pain, respiratory failure and likelihood of repeat procedures, it was decided that postoperative analgesia would be best provided by a continuous brachial plexus blockade. Proximal approaches to the brachial plexus were contraindicated due to the underlying lung pathology and also due to full anticoagulation with unfractionated heparin. Therefore an axillary brachial plexus blockade was performed using ultrasound guidance to prevent damage to the newly palpable artery. The neurovascular bundle was clearly seen using a 5 to 10 MHz ultrasound. The nerve stimulator was set to deliver 1.6 mA (100 ms, 2 Hz) and using the long axis view, the tip of a 50 mm insulated needle was seen to approach the median nerve. However no twitches could be elicited. The stimulating current was increased and faint finger flexion observed at 1.9 mA. The motor response did not increase above 1.9 mA, and disappeared below 1.9 mA. Twenty mL of 0.75% ropivacaine was injected, with immediate loss of twitches, and was seen to surround the neurovascular bundle. A perineural catheter was then inserted through the needle. On emergence from anaesthesia the patient was comfortable and an infusion of ropivacaine 0.2% commenced. The patient remained pain-free on the ward and the indwelling perineural catheter was later used to provide anaesthesia for surgical re-exploration and a dressings change at 48 hours. The catheter was inadvertently removed on the ward after three days. After 4 hours the patient began to complain of severe pain in his forearm although his hand remained
464
numb, and the arm immobile. The catheter was re-sited, again using ultrasound, with similar success. This case again illustrates how ultrasound was vital in establishing regional anesthesia due to lack of traditional endpoints, and the importance of avoiding damage to local structures. Furthermore, it describes the use of regional analgesia after decompression of the forearm compartments. There are multiple reports of regional anaesthesia masking compartment syndrome,2,3 but we found no reports of its use after fasciotomy to relieve compartment syndrome. Matthew Ward, M.B. Ch.B., F.R.C.A. Kirk Joseph Christopher Langley, M.R.C.P., F.R.C.A. Department of Anaesthesia and Pain Medicine Royal Perth Hospital Perth, Australia References 1. Assmann N, McCartney CJ, Tumber PS, Chan VW. Ultrasound guidance for brachial plexus localization and catheter insertion after complete forearm amputation. Reg Anesth Pain Med 2007;32:93. 2. Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg 1996;78:499-500. 3. Davis ET, Harris Q, Keene D, Porter K, Manji M. The use of regional anaesthesia in patients at risk of acute compartment syndrome. Injury 2006;37:128-133.
Accepted for publication June 13, 2007. doi:10.1016/j.rapm.2007.06.006
John Bonica Did Not Recognize John Lundy as an Inspiration of His Pain Clinic Model To the Editor: I read with interest the article by Sen et al.1 I am glad that Bonica’s contribution to the fields of pain and anesthesiology are being discussed. However, some of the information in the article is incorrect2 and possibly the conclusion is also erroneous. In 1987, in honor of Bonica’s seventieth birthday, a Symposium was organized in Venice and he was asked to deliver a lecture, “Wrestling with Pain,” an autobiographical summary of his professional and personal life which was videotaped.3 In the section covering the time from graduation from Marquette Medical School in 1941 until the establishment of the concept of the interdisciplinary pain clinic at Madigan Army Hospital, the projected slides show the following selected points: 1942 - 4/44 Anesthesiology Residency – St. Vincent Hospital NYC . . .
Regional Anesthesia and Pain Medicine, Vol 32, No 5 (September–October), 2007: pp 464 –466
Letters to the Editor 6/44 Chief of Anesthesia, Madigan General Hospital (Army) . . . 8/44 S. G. ⬎ Director School of Anesthesia . . . ⫹ Management of Pain . . .
are incorrect and the hypothesis that Bonica’s model of pain therapy was influenced by John Lundy is very likely erroneous. Costantino Benedetti, M.D. Department of Anesthesiology The Ohio State University Columbus, OH
In the video, Bonica states: “. . . following this [graduation from medical school, author note], I went to St. Vincent Hospital in New York which at the time it was considered one of the elite hospitals of New York City . . . In 1942, the war had just started in the United States; there was an abbreviated internship and an abbreviated residency in anesthesiology. Because most faculty anesthesia staff had gone to war, I had one day of instruction on giving anesthesia and for the rest 18 months I was the chief resident of anesthesia . . . Now this hospital . . . was staffed by the great leaders of American anesthesia: Paul Wood, Rovestine . . . and many others. Surgical anesthesia was absolutely first class . . . . Soon after my training, I was inducted in the United States Army, and to my great, great satisfaction and pleasure I was assigned as chief of anesthesia of the biggest military hospital in the world . . . Soon thereafter the Surgeon General of the Army sent me a telegram saying ‘In addition to your other duties . . . you will be responsible for the management of patients with pain.’ This was the time that Le Riche, the great French surgeon, had popularized regional techniques for managing patients with pain and, of course, Livingston had just finished his book on the subject . . . . I had had no training in pain therapy; I knew nothing about pain except how to prevent it with general anesthesia. So I read all the books quickly . . . I taught regional anesthesia to myself by running to the pathology room and obviously I was frustrated because I could not handle the problem. Then I contacted colleagues in neurosurgery, neurology in other places for help. And found that the traditional method of communication, that is for the patient to be seen by each of the consultants and then to try to get this information was very difficult, time consuming, inefficient. And so I got the bright idea, I thought, of getting them together at lunch to discuss these pain problems. And this was really the beginning of the multidisciplinary program approach to pain diagnosis and therapy . . .⬙ From this presentation it is clear that Bonica started his work at Madigan in June 1944 and not in 1942. His main innovation in the field of pain was not that of involving different specialists in the diagnosis and treatment of pain (indeed it already existed), instead it was to have these individuals meet twice weekly to discuss among each other the issues of each individual pain patient as opposed to relying on the written consultants’ notes. He did not recognize John Lundy as one of his inspirations for pain treatment; instead he spoke of LeRiche and William Livingston. There is no question that Bonica knew Lundy quite well, as he spoke to me about him on several occasions. In addition, Bonica’s medical library has several books that were part of Dr. Lundy’s library. However this relationship developed later in Bonica’s life as confirmed by his daughter Angela (telephone conversation with Mrs. Angela Bonica De Simone, June 19, 2007). In conclusion, some of the dates reported in the article
465
References 1. Sen S, Martin DP, Bacon DR. Exploring origins: Was John Bonica’s model of modern-day pain management influenced by John Lundy’s earlier work? Reg Anesth Pain Med 2007;32:258-262. 2. Benedetti C, Chapman R. John J. Bonica: A life dedicated to the alleviation of human suffering. In: Benedetti C, Chapman CR, Giron G, eds. Advances in Pain Research and Therapy. Vol. 14: Opioid Analgesia. New York: Raven Press; 1990:xv-xxii. 3. Bonica J. Wrestling with Pain [videotape]. Venice: Benedetti C. Videotape library; 1987.
Accepted for publication June 27, 2007. doi:10.1016/j.rapm.2007.06.387
Reply to Dr. Benedetti To the Editor: We thank Professor Costantino Benedetti for his very thoughtful, insightful comment on our article. We agree that Bonica’s work began at Madigan in 1944. Somehow in writing our article, we made an error. We believe that we had somehow substituted the end of Dr. Bonica’s medical school training in 1942, with his subsequent residency training in 1944. We apologize for this regrettable error, although it does not alter our thesis. Historical methods are often somewhat different than basic science or clinic research methodology. There is ample evidence of John Lundy’s influence in John Bonica’s career even if they did not know each other at the time. Bonica’s residency was at Saint Vincent’s Hospital in New York City where he was trained by Paul Wood, Emery Rovenstine, and other major figures of the New York City anesthesia scene. All were close personal acquaintances of John Lundy through the Anaesthetists’ Travel Club and the American Society of Anesthesiologists. During Bonica’s residency, Lundy did travel to New York, and therefore they may well have met. Even if they did not make a personal connection, Wood and others would have spoken about Bonica to Lundy. Second, Lundy was heavily involved in the placement of anesthesiologists within military hospitals and the Lundy correspondence housed in the Mayo Foundation Archives is replete with examples of Lundy writing to command staff to have physicians placed appropriately within the specialty.1 Bonica’s commanding surgeon at Madigan, Joel Deutermann, was familiar with Lundy. The practice pattern is similar. The textbook Bonica most likely used was Lundy’s2 because it was the official text for the military short course and the most current comprehensive reference available for residency training. Lundy’s textbook has a large section on regional anesthesia.